Can CALLY score predict mortality and ICU stay in elderly patients with sepsis?

Background: Sepsis remains a leading cause of mortality, and accurate, early identification of high-risk sepsis patients is essential in elderly adults. Scoring systems, such as Quick Sequential Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS), are widely used but have limitations in predicting outcomes in elderly patients. The CRP-albumin-lymphocyte (CALLY) score is a potential alternative, but its role in predicting mortality and Intensive Care Unit (ICU) admission in older sepsis patients is limited. Methods: This retrospective cohort study included patients aged 65 years and older admitted with sepsis to a tertiary hospital covering the years 2021 to 2023. Demographic data, qSOFA, SIRS, and CALLY scores, length of hospital and ICU stay, and mortality outcomes were collected. Statistical analyses were conducted using t-tests and chi-square tests, with a significance threshold set at p < 0.05. Results: The study included 150 patients, with a mean age of 81.1 ± 8.3 years. 50 patients (33.3%) died, and 42 patients (28.0%) required ICU admission. Patients who died had significantly higher qSOFA and SIRS scores, but lower CALLY scores compared to survivors. ICU length of stay ranged from 1 to 34 days, with a mean of 10.6 ± 8.4 days. ICU admission rates were higher in patients who died (p < 0.001), but length of stay did not differ significantly between survivors and nonsurvivors (p = 0.129). Although CALLY scores did not significantly differ between ICU and non-ICU groups, qSOFA scores were higher in those admitted to the ICU (p = 0.006). Conclusions: The qSOFA score effectively predicted ICU admission and mortality in older sepsis patients, but its reliability may be compromised in those with cognitive decline. The CALLY score demonstrated potential as an adjunct tool for mortality prediction. Further research is necessary to develop and validate new scoring systems for sepsis assessment in elderly patients.

Sepsis; Emergency department; Old patients; CALLY score

[1] La Via L, Sangiorgio G, Stefani S, Marino A, Nunnari G, Cocuzza S, et al. The global burden of sepsis and septic shock. Epidemiologia. 2024; 5: 456–478.

[2] Oczkowski S, Alshamsi F, Belley-Cote E, Centofanti JE, Hylander Møller M, Nunnaly ME, et al. Surviving Sepsis Campaign Guidelines 2021: highlights for the practicing clinician. Polish Archives of Internal Medicine. 2022; 132: 7–8.

[3] Chau EYW, Bakar AA, Zamhot AB, Zaini IZ, Binti Adanan SN, Sabardin DMB. An observational study on the impact of overcrowding towards door-to-antibiotic time among sepsis patients presented to emergency department of a tertiary academic hospital. BMC Emergency Medicine. 2024; 24: 58.

[4] Simpson SQ. New sepsis criteria: a change we should not make. CHEST. 2016; 149: 1117–1118.

[5] Mancinetti F, Marinelli A, Boccardi V, Mecocci P. Challenges of infectious diseases in older adults: from immunosenescence and inflammaging through antibiotic resistance to management strategies. Mechanisms of Ageing and Development. 2024; 222: 111998.

[6] Marti HP, Pavía López AA, Schwartzmann P. Safety and tolerability of β-blockers: importance of cardioselectivity. Current Medical Research and Opinion. 2024; 40: 55–62.

[7] De Groot B, Stolwijk F, Warmerdam M, Lucke JA, Singh GK, Abbas M, et al. The most commonly used disease severity scores are inappropriate for risk stratification of older emergency department sepsis patients: an observational multi-centre study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2017; 25: 91.

[8] Lo RSL, Leung LY, Brabrand M, Yeung CY, Chan SY, Lam CCY, et al. qSOFA is a poor predictor of short-term mortality in all patients: a systematic review of 410,000 patients. Journal of Clinical Medicine. 2019; 8: 61.

[9] Liu XY, Zhang X, Zhang Q, Ruan GT, Liu T, Xie HL, et al. The value of CRP-albumin-lymphocyte index (CALLY index) as a prognostic biomarker in patients with non-small cell lung cancer. Supportive Care in Cancer. 2023; 31: 533.

[10] Cui N, Zhang H, Chen Z, Yu Z. Prognostic significance of PCT and CRP evaluation for adult ICU patients with sepsis and septic shock: retrospective analysis of 59 cases. Journal of International Medical Research. 2019; 47: 1573–1579.

[11] Frenkel A, Novack V, Bichovsky Y, Klein M, Dreiher J. Serum albumin levels as a predictor of mortality in patients with sepsis: a multicenter study. Israel Medical Association Journal. 2022; 24: 454–459.

[12] Yang H, Li P, Cui Q, Ma N, Liu Q, Sun X, et al. Analysis of lymphocyte subsets in patients with sepsis and its impact on prognosis. Chinese Critical Care Medicine. 2023; 35: 702–706. (In Chinese)

[13] Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Critical Care Medicine. 2001; 29: 1303–1310.

[14] Zhang J, Zhao Q, Liu S, Yuan N, Hu Z. Clinical predictive value of the CRP-albumin-lymphocyte index for prognosis of critically ill patients with sepsis in intensive care unit: a retrospective single-center observational study. Frontiers in Public Health. 2024; 12: 1395134.

[15] Ramoni D, Tirandi A, Montecucco F, Liberale L. Sepsis in elderly patients: the role of neutrophils in pathophysiology and therapy. Internal and Emergency Medicine. 2024; 19: 901–917.

[16] Sanguanwit P, Yuksen C, Khorana J, Sutham K, Phootothum Y, Damdin S. Development of a clinical score for predicting 28-day mortality in geriatric sepsis patients; a cohort study. Archives of Academic Emergency Medicine. 2024; 12: e56.

[17] Finkelsztein EJ, Jones DS, Ma KC, Pabón MA, Delgado T, Nakahira K, et al. Comparison of qSOFA and SIRS for predicting adverse outcomes of patients with suspicion of sepsis outside the intensive care unit. Critical Care. 2017; 21: 73.

[18] Churpek MM, Snyder A, Han X, Sokol S, Pettit N, Howell MD, et al. Quick sepsis-related organ failure assessment, systemic inflammatory response syndrome, and early warning scores for detecting clinical deterioration in infected patients outside the intensive care unit. American Journal of Respiratory and Critical Care Medicine. 2017; 195: 906–911.

[19] Müller L, Hahn F, Mähringer-Kunz A, Stoehr F, Gairing SJ, Michel M, et al. Immunonutritive scoring for patients with hepatocellular carcinoma undergoing transarterial chemoembolization: evaluation of the CALLY index. Cancers. 2021; 13: 5018.

[20] Miyazaki R, Tamura M, Sakai T, Furukawa N, Yamamoto M, Okada H. Using the combined C-reactive protein and controlling nutritional status index for elderly non-small cell lung cancer. Journal of Thoracic Disease. 2024; 16: 4400–4408.

[21] Shiraishi T, Nonaka T, Tominaga T, Takamura Y, Oishi K, Hashimoto S, et al. The C-reactive protein-albumin-lymphocyte (CALLY) index is a useful predictor of postoperative complications in patients with a colonic stent for obstructive colorectal cancer: a Japanese multicenter study. Surgery Today. 2025; 55: 502–509.

[22] SAFE Study Investigators; Finfer S, McEvoy S, Bellomo R, McArthur C, Myburgh J, Norton R. Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis. Intensive Care Medicine. 2011; 37: 86–96.

[23] Delaney AP, Dan A, McCaffrey J, Finfer S. The role of albumin as a resuscitation fluid for patients with sepsis: a systematic review and meta-analysis. Critical Care Medicine. 2011; 39: 386–391.

[24] Jiang W, Zhong W, Deng Y, Chen C, Wang Q, Zhou M, et al. Evaluation of a combination “lymphocyte apoptosis model” to predict survival of sepsis patients in an intensive care unit. BMC Anesthesiology. 2018; 18: 89.

[25] Inoue S, Suzuki-Utsunomiya K, Okada Y, Taira T, Iida Y, Miura N, et al. Reduction of immunocompetent T cells followed by prolonged lymphopenia in severe sepsis in the elderly. Critical Care Medicine. 2013; 41: 810–819.